Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-1595
2. Registrant Information.
Registrant Reference Number: 2011-6
Registrant Name (Full Legal Name no abbreviations): BASF Canada
Address: 100 Milverton 5th floor
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5R4H1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
02-APR-11
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW JERSEY
6. Date incident was first observed.
02-APR-11
Product Description
7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.
Active(s)
PMRA Registration No.
PMRA Submission No. 2010-0613
EPA Registration No. 7969-285
Product Name: Phantom
7. b) Type of formulation.
Other (specify)
pressurized spray
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Prescription treatment brand phantom pressurized insecticide;exposure occured April 2 9:35Am CDT. A PCO applied product in house in AM.Dog was in house at time.Dog may have licked product or may have gotten some on fur and licked it.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Shih Tzu
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.5
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- Nervous and Muscular Systems
- General
- Symptom - Hyperthermia
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
1
Hour(s) / Heure(s)
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dog wa staken to vet, endotracheal intubation performed. Died at 10:40.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here